Background: There is increased interest in the ability of primary care physician practices to measure and improve performance. No studies have looked at primary care practices that evaluate their performance on multiple facets of the organization. This study addresses this deficit by conducting an in-depth examination of performance management in primary care practices in Virginia. A comparative case study approach of practices that are "performance driven" and those that are "not performance driven" will allow us to identify practice characteristics, environmental elements, and other attributes that distinguish these two groups. Performance driven primary care practices are those that review and attempt to improve their performance on quality of care, patient satisfaction, growth and innovation, and financial performance. Specific Aims: The specific aims of the study are to: (1) understand what motivates performance driven primary care practices to engage in performance management activities, (2) identify external and internal practice characteristics that are facilitators or barriers to performance management, (3) characterize successful strategies of performance driven primary care practices, (4) identify what outcomes have resulted from performance measurement efforts, and (5) refine a conceptual framework for performance management in primary care practices. Methods: The methodology uses an in-depth comparative case study of eight primary care practices to examine aspects of the practice and environment that influence performance management. The method involves the use of quantitative and qualitative data collection tools: a survey;document reviews;key informant interviews;and observation of performance measurement, reporting, and improvement activities. Outcomes: This study will characterize how practices develop into "performance driven" entities and will identify effective strategies that could be used by other, similar practices. The study will produce a framework for performance management in primary care practices. SIGNIFICANCE: An in-depth examination of performance driven primary care practices would provide detailed information on successful implementation and use of performance management. This information would establish a knowledge base for future intervention efforts and evaluations of performance initiatives in primary care.